Use this page to develop a case on atherothrombosis
Overview of Atherothrombosis:
Atherothrombosis, characterized by an atherosclerotic lesion disruption with superimposed thrombus formation. This condition develops over a long period of time, possibly even as a child. This occurs through the processes of atherogenesis and thrombogenesis. Atherogenesis is the formation of atheromatous lesions in the arterial wall. Thrombogenesis is the process of clot or thrombus formation. The atherosclerotic lesion is first formed by the adhesion of the monocytes/macrophages to the vascular endothelium. The monocytes/macrophages bind and penetrate into arterial media producing proinflamatory cytokines and growth factors. The monocytes ingestion of oxidized low-density lipoprotein (LDL) causes enlargement to form foam cells. The growth factor production leads to smooth mucscle proliferation and atheromatous plaque formation, thicked wall, and narrow lumen. If this arteromatous plaque ruptures, then an arterial thrombosis occurs. The rupture exposes the circulating blood to arterial collagen and tissue factors from monocytes/macrophages and activates platelets and coagulation (Carranza). The platelets and fibrin accumulate forming a thrombus. The thrombus may occlude the blood vessel causing an ischemic event, such as angina and myocardial infraction. If the thrombus breaks off from the blood vessel, it becomes an embolus. This may cause occlusion of a blood vessel leading to an acute event, such as myocardial infraction or cerebral infaction.
The etiology for this condition may be multiple factors, include genetic and enviromental factors. Risk factors include age, cholesterol levels, hypertension, diabetes, and smoking. Patients with hyperinflammatory monocytes/macrophages phenotype (M0+), have an exaggerated response to inflammation, making them more suseptible to atherothrombosis by the initiation of adhesion of the monocytes. Periodontitis plays an important role, due to the bacteria present. Systemic infections affect the viscosity of the blood, elevating the coagulation factor antigen, increasing the risk for thrombosis.
Signs and Symptoms for angina pectoris may be brief (5-15 minutes) aching, heavy, squeezing pressure or thightness in the midchest region, and pain may radiate into the left or right arm to the neck or lower jaw. from the temporary ischemia of the myocardium. If it is stable the pain is predictable and consistent over time. Physical activity, stress, or eating can induce the chest pain, The use of nitroglycerine relieves the pain. Unstable angina is induced by less effort or even at rest. The pains are more intense, increases in frequency, and last longer than 15 minutes. This pain is not readily relieved with the use of nitrogylecrin, and are at risk for developing a Myocardial Infarction. Prinzmetal's Variant angina is the least common, and occurs at rest. There are focal spasms of the coronary artery by the higher varying amounts of atherosclerosis.
Treatment for stable angina pectoris involves identifying underlying condition percipitating angina, reduction in coronary risk factors, adjustments in lifestyle, pharmacologic management, and revasculatization.
Identifying underlying condition that may exacerbate angina (such as anemia,hyperthyroidism, obesity)
Reduction in coronary risk factors (such as smoking, hypertension, hyperlipidemia)
Adjustments in lifestyle (such as rest, reduce stress)
The patient is a 45 year old male, his last dental cleaning was approximately one year ago. He was hospitalized about a year ago due to chest pain, and currently under the care of a physician. He has been trying to maintain proper oral hygiene, but due to the enlarged gingival tissue it has been difficult. He has been trying to floss, but has caused gingival trauma a few times and decided just to brush. Patient also complains of drymouth, bleeding gums, and pain to hot and cold on tooth #10. He wants to get his teeth cleaned as soon as possible. His physician has placed him on a strict diet to control his cholesterol, and is currently taking the following medications nitroglycerin, Propranolol, Nifedipine, and Plavix.
Gingival Description:
Free is generalized erythematous, bulbous, blunted, localized clefting on facial of # 7,10,21-24, & 26; fibro-edemic, and shiny. Attached is generalized erythematous, loss of stippling, edemic, and shiny.
Assessment Findings: Salivary flow is inadequate. MBI: 45%, BOP: 76%. Probing depths are generally 3-4 mm with localized 5-7mm. Fremitus: (+) # 7-10. Mobility: (+) 7-10, 22-27. Recession is not noted. Furcations Class I On buccal of #18, 19 (but may be Class II or III once inflammation decreases or if gingivoectomy is performed). Predict that this patient has a calculus code of Medium.
Oral Hygiene Instructions: It would be recommended that this patient use an extra soft toothbrush and reviewing the Bass technique. Since this patient has a concern with flossing because of gingiva trauma we could recommend a rubber tip stimulator or a Soft-Picks interpoximal periodontal aids. A Waterpix can be given to patient to irrigate interproximal if needed. Also this patient has informed us about dry mouth, patient can be recommended Oasis or Biotene products to stimulate salivary flow. Nutritional Counseling may be done on this patient since he has a cardiac problem and a diet has been suggested by the physician. Patient may be aware of possible gingivectomy to allow for increase accessibility for patient to maintain as well as us, clinicians. Finally we can use CHX to irrigate the pockets with 4mm or more.
Treatment Plan Appointments:
FOR EACH VISIT IT IS IMPORTANT TO HAVE PATIENT'S NITROGLYCERIN IN AN ACCESSIBLE LOCATION IN CASE OF AN EMERGENCY. ALWAYS MAKE SURE THE MEDICATION IS CURRENT AND NOT EXPIRED.
Appointment 1: RMH, Vitals, Medical Consult: This consultation would be addressed to the cardiologist to makes sure the patient is safe to be treated with the use of anesthesia with epinepherine and to know the effect of clotting with this patient (INR, Clotting time). The reason for this is the recent hospitalization (within 6 months), the medications the patient is taken, and if there is any need for prophylaxis.
*receive Medical Consult prior to next appointment
Appointment 2: RMH, Vitals, Gathered Assessment, FMX/Panoramic Radiograph, DDS exam, Second Check-in, PI and OHI was given. During this visit the oral hygiene discussed was the evaluation of the technique of brushing with the recommendation of a ultra-soft toothbrush. Patient was given the ok not to floss due to the bleeding and trauma being created, instead a rubber tip stimulator was introduced. Patient is also given instruction for nutritional counseling informing the risk factor of his systemic disease to the correlation of periodontitis. Instructions of a 5-7day diary is given to the patient and informed to bring diary on next visit.
Appointment 3: RMH, Vitals
OHI: Reviewed at home care with the use of the ultra soft toothbrush and rubber tip stimulus. Introduced and gave instruction for the use of Biotene to patient so that he can see if the product helps with saliva stimulation for his dry mouth. Will receive the nutritional counseling and check for any omission.
Scale LR with anesthesia and irrigate with CHX in pockets greater than 4 mm. Post operative instructions given to patient that he may rinse with salt water as well as take an NSAID if needed for discomfort.
Appointment 4:
RMH, Vitals OHI: Review oral hygiene products from previous visits, introduced the Soft-Picks as interproximal aids since it allows for the patient to get in between the teeth as an alternative option for flossing. Give patient thorough analysis of diet intake and possibly give patient a sample menu that is directed to fulfill the dietary consumption of the patient but include foods that are good for cardiac patients.
Scale UR with anesthesia and irrigate with CHX in pockets greater than 4 mm. Post operative instructions given to patient that he may rinse with salt water as well as take an NSAID if needed for discomfort.
Appointment 5: RMH, Vitals
OHI: Evaluate the aid given to patient for at home care the previous visits and evaluate the patients likes or dislike for the salivary enhancer. If patient is not satisfied patient can be given Oasis as an alternative. Also evaluate patient's diet and see if their is any aid or recommendations needed.
Scale LL with anesthesia and irrigate with CHX in pockets greater than 4 mm. Post operative instructions given to patient that he may rinse with salt water as well as take an NSAID if needed for discomfort.
Appointment 6: RMH, Vitals
OHI: Evaluate the recommendations for oral hygiene care at home and suggest frequency to patient on brushing and use of aids. You can give patient option of an irrigant system to use at home like the Waterpix. Evaluate patients diet and help with any improvement or assistance.
Scale UL with anesthesia and irrigate with CHX in pockets greater than 4 mm. Post operative instructions given to patient that he may rinse with salt water as well as take an NSAID if needed for discomfort.
Appointment 7: RMH, Vitals 4-6 week reevaluation.
Give patient prognosis of their scaling and inform the improvement perceived with the gingivectomy if patient is willing to see even more improvement. Evaluate at home Oral Hygiene care and give encouraging recommendations to patient.
Fluoride treatment will be administered and re-care interval will be determined at this time.
Additional Treatment: Patient can be given the alternative to have an gingivectomy done to decrease the gingiva by excision or removal. The patient can be informed that this can lead to healthy gingival contour. Also along with this if needed in a different phase the patient can ask for gingivoplasty. This allows for reshaping gingiva to increase physiological contours, but is not intended to eliminate pocket depths.
1. Atherothombosis occurs through the process of thrombogenesis and atherogenesis. The first process is thrombogenesis, then followed by atherogenesis.
A. Both statements are true
B. Both statemetns are false
C. First statement is true, and the second statement is false
D. First statement is false, and the second statement is true.
2. Patients with atherothrombosis, are at risk for the following life threatening conditions
A. Angina Pectoris
B. Myocardial Infarction
C. Cerebral Infarction
D. all of the above
3. Pain for both stable and unstable angina pectoris can be relieved by the use of nitroglycerin. Stable angina, the pain is predictable and consistent, lasting 5 to 15 minutes.
A. Both statements are true
B. Both statements are false
C. First statement is true and second statement is false.
D. First statement is false and second statement is true.
4. Which of the following type of medications has a side effect of gingival enlargement.
A. Nitrates
B. Beta Blockers
C. Calcium Channel Blocker
D. Anti-Platelet Agent
5. Reduction of stress and pain control is important during each appointment. Physical activity and stress can induce chest pains, if uncontrolled it may lead to a myocardial infarction.
A. Both statements are true.
B. Both statements are false.
C. First statement is true and second statement is false
D. First statement is false and second statement is true
6. Which of the following is the most important treatment plan and recommendations for this patient
A. Oral Hygiene Education
B. Rinses to reduce xerostomia
C. Antimicrobial rinses, such as CHX
D. Gingivectomy
7. What would you contribute to the reason for pain on tooth #10?
A. Poor Oral Hygiene
B. Priodontal Abcess
C. Endodonic Involvement
D. Gingival Hyperplasia
8. Nutritional counseling is important for patient's with atherothrombosis to reduce diatery fats. Lipids will induce the production of foam cell increasing atheromatous plaque formation in the blood vessels.
A. Both statements are true.
B. Both statements are false.
C. First statement is true and second statement is false.
D. First statement is false and second statement is true.
9. The following conditions increases the risk for the development of atherothrombosis
A. Anemia
B. Obesity
C. Hypothyroidism
D. Smoking
E. B & D
10. Atherothrombosis is associated with ischemic heart disease. Ischemic symptoms occur from the deprivation of oxygen to a portion of the myocardium, due reduction in blood flow.
A. Both statements are true
B. Both statements are false
C. First statement is true and second statement is false
D. First statement is false and second statement is true
Case #7 Atherothrombosis
Overview of Atherothrombosis:
Atherothrombosis, characterized by an atherosclerotic lesion disruption with superimposed thrombus formation. This condition develops over a long period of time, possibly even as a child. This occurs through the processes of atherogenesis and thrombogenesis. Atherogenesis is the formation of atheromatous lesions in the arterial wall. Thrombogenesis is the process of clot or thrombus formation. The atherosclerotic lesion is first formed by the adhesion of the monocytes/macrophages to the vascular endothelium. The monocytes/macrophages bind and penetrate into arterial media producing proinflamatory cytokines and growth factors. The monocytes ingestion of oxidized low-density lipoprotein (LDL) causes enlargement to form foam cells. The growth factor production leads to smooth mucscle proliferation and atheromatous plaque formation, thicked wall, and narrow lumen. If this arteromatous plaque ruptures, then an arterial thrombosis occurs. The rupture exposes the circulating blood to arterial collagen and tissue factors from monocytes/macrophages and activates platelets and coagulation (Carranza). The platelets and fibrin accumulate forming a thrombus. The thrombus may occlude the blood vessel causing an ischemic event, such as angina and myocardial infraction. If the thrombus breaks off from the blood vessel, it becomes an embolus. This may cause occlusion of a blood vessel leading to an acute event, such as myocardial infraction or cerebral infaction.
The etiology for this condition may be multiple factors, include genetic and enviromental factors. Risk factors include age, cholesterol levels, hypertension, diabetes, and smoking. Patients with hyperinflammatory monocytes/macrophages phenotype (M0+), have an exaggerated response to inflammation, making them more suseptible to atherothrombosis by the initiation of adhesion of the monocytes. Periodontitis plays an important role, due to the bacteria present. Systemic infections affect the viscosity of the blood, elevating the coagulation factor antigen, increasing the risk for thrombosis.
Signs and Symptoms for angina pectoris may be brief (5-15 minutes) aching, heavy, squeezing pressure or thightness in the midchest region, and pain may radiate into the left or right arm to the neck or lower jaw. from the temporary ischemia of the myocardium. If it is stable the pain is predictable and consistent over time. Physical activity, stress, or eating can induce the chest pain, The use of nitroglycerine relieves the pain. Unstable angina is induced by less effort or even at rest. The pains are more intense, increases in frequency, and last longer than 15 minutes. This pain is not readily relieved with the use of nitrogylecrin, and are at risk for developing a Myocardial Infarction. Prinzmetal's Variant angina is the least common, and occurs at rest. There are focal spasms of the coronary artery by the higher varying amounts of atherosclerosis.
Treatment for stable angina pectoris involves identifying underlying condition percipitating angina, reduction in coronary risk factors, adjustments in lifestyle, pharmacologic management, and revasculatization.
Dental Implications
Medical History:
The patient is a 45 year old male, his last dental cleaning was approximately one year ago. He was hospitalized about a year ago due to chest pain, and currently under the care of a physician. He has been trying to maintain proper oral hygiene, but due to the enlarged gingival tissue it has been difficult. He has been trying to floss, but has caused gingival trauma a few times and decided just to brush. Patient also complains of drymouth, bleeding gums, and pain to hot and cold on tooth #10. He wants to get his teeth cleaned as soon as possible. His physician has placed him on a strict diet to control his cholesterol, and is currently taking the following medications nitroglycerin, Propranolol, Nifedipine, and Plavix.Gingival Description:
Free is generalized erythematous, bulbous, blunted, localized clefting on facial of # 7,10,21-24, & 26; fibro-edemic, and shiny.Attached is generalized erythematous, loss of stippling, edemic, and shiny.
Assessment Findings:
Salivary flow is inadequate. MBI: 45%, BOP: 76%. Probing depths are generally 3-4 mm with localized 5-7mm. Fremitus: (+) # 7-10. Mobility: (+) 7-10, 22-27. Recession is not noted. Furcations Class I On buccal of #18, 19 (but may be Class II or III once inflammation decreases or if gingivoectomy is performed). Predict that this patient has a calculus code of Medium.
Oral Hygiene Instructions:
It would be recommended that this patient use an extra soft toothbrush and reviewing the Bass technique. Since this patient has a concern with flossing because of gingiva trauma we could recommend a rubber tip stimulator or a Soft-Picks interpoximal periodontal aids. A Waterpix can be given to patient to irrigate interproximal if needed. Also this patient has informed us about dry mouth, patient can be recommended Oasis or Biotene products to stimulate salivary flow. Nutritional Counseling may be done on this patient since he has a cardiac problem and a diet has been suggested by the physician. Patient may be aware of possible gingivectomy to allow for increase accessibility for patient to maintain as well as us, clinicians. Finally we can use CHX to irrigate the pockets with 4mm or more.
Treatment Plan Appointments:
FOR EACH VISIT IT IS IMPORTANT TO HAVE PATIENT'S NITROGLYCERIN IN AN ACCESSIBLE LOCATION IN CASE OF AN EMERGENCY. ALWAYS MAKE SURE THE MEDICATION IS CURRENT AND NOT EXPIRED.
Appointment 1:
RMH, Vitals, Medical Consult: This consultation would be addressed to the cardiologist to makes sure the patient is safe to be treated with the use of anesthesia with epinepherine and to know the effect of clotting with this patient (INR, Clotting time). The reason for this is the recent hospitalization (within 6 months), the medications the patient is taken, and if there is any need for prophylaxis.
*receive Medical Consult prior to next appointment
Appointment 2:
RMH, Vitals, Gathered Assessment, FMX/Panoramic Radiograph, DDS exam, Second Check-in, PI and OHI was given. During this visit the oral hygiene discussed was the evaluation of the technique of brushing with the recommendation of a ultra-soft toothbrush. Patient was given the ok not to floss due to the bleeding and trauma being created, instead a rubber tip stimulator was introduced. Patient is also given instruction for nutritional counseling informing the risk factor of his systemic disease to the correlation of periodontitis. Instructions of a 5-7day diary is given to the patient and informed to bring diary on next visit.
Appointment 3:
RMH, Vitals
OHI: Reviewed at home care with the use of the ultra soft toothbrush and rubber tip stimulus. Introduced and gave instruction for the use of Biotene to patient so that he can see if the product helps with saliva stimulation for his dry mouth. Will receive the nutritional counseling and check for any omission.
Scale LR with anesthesia and irrigate with CHX in pockets greater than 4 mm. Post operative instructions given to patient that he may rinse with salt water as well as take an NSAID if needed for discomfort.
Appointment 4:
RMH, Vitals
OHI: Review oral hygiene products from previous visits, introduced the Soft-Picks as interproximal aids since it allows for the patient to get in between the teeth as an alternative option for flossing. Give patient thorough analysis of diet intake and possibly give patient a sample menu that is directed to fulfill the dietary consumption of the patient but include foods that are good for cardiac patients.
Scale UR with anesthesia and irrigate with CHX in pockets greater than 4 mm. Post operative instructions given to patient that he may rinse with salt water as well as take an NSAID if needed for discomfort.
Appointment 5:
RMH, Vitals
OHI: Evaluate the aid given to patient for at home care the previous visits and evaluate the patients likes or dislike for the salivary enhancer. If patient is not satisfied patient can be given Oasis as an alternative. Also evaluate patient's diet and see if their is any aid or recommendations needed.
Scale LL with anesthesia and irrigate with CHX in pockets greater than 4 mm. Post operative instructions given to patient that he may rinse with salt water as well as take an NSAID if needed for discomfort.
Appointment 6:
RMH, Vitals
OHI: Evaluate the recommendations for oral hygiene care at home and suggest frequency to patient on brushing and use of aids. You can give patient option of an irrigant system to use at home like the Waterpix. Evaluate patients diet and help with any improvement or assistance.
Scale UL with anesthesia and irrigate with CHX in pockets greater than 4 mm. Post operative instructions given to patient that he may rinse with salt water as well as take an NSAID if needed for discomfort.
Appointment 7:
RMH, Vitals 4-6 week reevaluation.
Give patient prognosis of their scaling and inform the improvement perceived with the gingivectomy if patient is willing to see even more improvement. Evaluate at home Oral Hygiene care and give encouraging recommendations to patient.
Fluoride treatment will be administered and re-care interval will be determined at this time.
Additional Treatment:
Patient can be given the alternative to have an gingivectomy done to decrease the gingiva by excision or removal. The patient can be informed that this can lead to healthy gingival contour. Also along with this if needed in a different phase the patient can ask for gingivoplasty. This allows for reshaping gingiva to increase physiological contours, but is not intended to eliminate pocket depths.
Multiple Choice Questions:
1. Atherothombosis occurs through the process of thrombogenesis and atherogenesis. The first process is thrombogenesis, then followed by atherogenesis.
A. Both statements are true
B. Both statemetns are false
C. First statement is true, and the second statement is false
D. First statement is false, and the second statement is true.
2. Patients with atherothrombosis, are at risk for the following life threatening conditions
A. Angina Pectoris
B. Myocardial Infarction
C. Cerebral Infarction
D. all of the above
3. Pain for both stable and unstable angina pectoris can be relieved by the use of nitroglycerin. Stable angina, the pain is predictable and consistent, lasting 5 to 15 minutes.
A. Both statements are true
B. Both statements are false
C. First statement is true and second statement is false.
D. First statement is false and second statement is true.
4. Which of the following type of medications has a side effect of gingival enlargement.
A. Nitrates
B. Beta Blockers
C. Calcium Channel Blocker
D. Anti-Platelet Agent
5. Reduction of stress and pain control is important during each appointment. Physical activity and stress can induce chest pains, if uncontrolled it may lead to a myocardial infarction.
A. Both statements are true.
B. Both statements are false.
C. First statement is true and second statement is false
D. First statement is false and second statement is true
6. Which of the following is the most important treatment plan and recommendations for this patient
A. Oral Hygiene Education
B. Rinses to reduce xerostomia
C. Antimicrobial rinses, such as CHX
D. Gingivectomy
7. What would you contribute to the reason for pain on tooth #10?
A. Poor Oral Hygiene
B. Priodontal Abcess
C. Endodonic Involvement
D. Gingival Hyperplasia
8. Nutritional counseling is important for patient's with atherothrombosis to reduce diatery fats. Lipids will induce the production of foam cell increasing atheromatous plaque formation in the blood vessels.
A. Both statements are true.
B. Both statements are false.
C. First statement is true and second statement is false.
D. First statement is false and second statement is true.
9. The following conditions increases the risk for the development of atherothrombosis
A. Anemia
B. Obesity
C. Hypothyroidism
D. Smoking
E. B & D
10. Atherothrombosis is associated with ischemic heart disease. Ischemic symptoms occur from the deprivation of oxygen to a portion of the myocardium, due reduction in blood flow.
A. Both statements are true
B. Both statements are false
C. First statement is true and second statement is false
D. First statement is false and second statement is true